Healthcare Provider Details

I. General information

NPI: 1689633240
Provider Name (Legal Business Name): BAYSIDE MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 06/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5720 STONERIDGE MALL RD SUITE 240
PLEASANTON CA
94588-2828
US

IV. Provider business mailing address

11875 DUBLIN BLVD SUITE C140
DUBLIN CA
94568-2843
US

V. Phone/Fax

Practice location:
  • Phone: 925-463-1234
  • Fax: 925-463-9599
Mailing address:
  • Phone: 925-587-2505
  • Fax: 925-587-2511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: BUDD NORMAN SHENKIN
Title or Position: OWNER/PRESIDENT
Credential: MD
Phone: 925-587-2505